1
|
A Narrative Review Discussing the Efficiency of Personalized Dosing Algorithm of Follitropin Delta for Ovarian Stimulation and the Reproductive and Clinical Outcomes. Diagnostics (Basel) 2023; 13:diagnostics13020177. [PMID: 36672987 PMCID: PMC9858569 DOI: 10.3390/diagnostics13020177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/24/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023] Open
Abstract
Background: Follitropin delta is the third recombinant human follicle-stimulating hormone (r-hFSH) expressed in a host cell line of human fetal retinal origin that currently emphasizes that the actual tendency of administration is a personalized dosing algorithm based on the anti-Müllerian hormone (AMH) and body mass index (BMI) for ovarian stimulation. Methods: In this context, we aimed, in the present manuscript, to gather all available data published between 2018-2022 regarding the co-administration and administration of follitropin delta and the clinical outcomes reported following an in vitro fertilization (IVF). Results: Follitropin delta is non-inferior in contrast to its previously launched agents for ovarian stimulation, enhancing a similar-to-superior response reflected by both the reproductive and pregnancy outcomes in parallel with a low risk of ovarian hyperstimulation syndrome (OHSS), being well tolerated. The body weight and AMH level are factors that may influence the outcome in a patient. Despite controversy and results that refute these arguments on several occasions, follitropin delta exceeds the benefits of conventional dosing with either follitropin alfa or follitropin beta. Thus, all post hoc, derived analyses and subsets of patients that participated in subsequent studies support this statement. Conclusions: Despite the relatively limited spectrum of data in the current literature, most authors brought potent proof, supporting the subsequent use of this drug depending on the patient's profile and overcoming ethnic-related limitations. Although others contradict these observations, this topic and drug possess substantial potential, which is why additional studies are mandatory to fill the existing gaps in our knowledge and expand these experiences at a larger scale supported by the obtained reproductive and clinical outcomes that clearly indicate an overcoming of all limitations.
Collapse
|
2
|
Fernández Sánchez M, Višnová H, Larsson P, Yding Andersen C, Filicori M, Blockeel C, Pinborg A, Khalaf Y, Mannaerts B. OUP accepted manuscript. Hum Reprod 2022; 37:1161-1174. [PMID: 35451013 PMCID: PMC9156848 DOI: 10.1093/humrep/deac061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/03/2022] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION SUMMARY ANSWER WHAT IS KNOWN ALREADY STUDY DESIGN, SIZE, DURATION PARTICIPANTS/MATERIALS, SETTING, METHODS MAIN RESULTS AND THE ROLE OF CHANCE LIMITATIONS, REASONS FOR CAUTION WIDER IMPLICATIONS OF THE FINDINGS STUDY FUNDING/COMPETING INTEREST(S) TRIAL REGISTRATION NUMBER TRIAL REGISTRATION DATE DATE OF FIRST PATIENT’S ENROLMENT
Collapse
Affiliation(s)
- Manuel Fernández Sánchez
- IVI-RMA Seville, Seville, Spain
- Departament of Surgery, Universidad de Sevilla, Seville, Spain
- Department of Molecular Biology and Biochemical Engineering, Universidad Pablo de Olavide, Seville, Spain
- Fundacion IVI, Instituto Investigación Sanitaria La Fe, Valencia, Spain
| | | | - Per Larsson
- Global Biometrics, Ferring Pharmaceuticals, Copenhagen, Denmark
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, Copenhagen University Hospital and Faculty of Health Science, Copenhagen University, Copenhagen, Denmark
| | | | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Anja Pinborg
- Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Yacoub Khalaf
- Assisted Conception Unit, Guy’s Hospital, London, UK
| | - Bernadette Mannaerts
- Correspondence address. Reproductive Medicine & Maternal Health, Ferring Pharmaceuticals, Amager Strandvej 405, 2770 Kastrup, Denmark. E-mail:
| | | |
Collapse
|
3
|
Sirard MA. The two-step process of ovarian follicular growth and maturation in mammals can be compared to a fruit ripening where quality depends on the second step. Biol Reprod 2021; 106:230-234. [PMID: 34939644 DOI: 10.1093/biolre/ioab236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/26/2021] [Accepted: 12/20/2021] [Indexed: 11/12/2022] Open
Abstract
In human IVF, the main uncertainty factor impacting on success is oocyte quality, which largely depends on the follicular status at the time of collection. Decades of debate ensued to find the perfect stimulation protocol demonstrated the complexity of the ovarian response to exogenous gonadotropins and the dynamic nature of late folliculogenesis. Although several follicular markers, proteins, RNA from granulosa cells or microRNA and follicular fluid metabolites have been associated with outcome, the possibility to influence them during stimulation remains elusive. The heterogeneity of the follicle's maturity following control ovarian stimulation is also an important factor to explain average poor oocyte quality still observed today. In this review, the analogy between the apple ripening on the tree and follicular development is presented to focus the attention on a biphasic process: growth and differentiation. The molecular analysis of the progressive follicular differentiation indicates 2 competing phenomena: growth and differentiation where a delicate balance must operate from one to the other to ensure proper maturity at ovulation. As long as FSH stimulates growth, follicles remain green, and it is only when FSH is replaced by LH that the ripening process begins, and "apples" become red. Both fruits, follicles and apples, depend on a perfect timing of events to generate offspring.
Collapse
Affiliation(s)
- Marc-André Sirard
- Centre de recherche en reproduction, développement et santé intergénérationnelle (CRDSI).,Département des Sciences Animales, Faculté des sciences de l'agriculture et de l'alimentation, Université Laval, Québec, Canada
| |
Collapse
|
4
|
Lawrenz B, Melado L, Digma S, Sibal J, Coughlan C, Andersen CY, Fatemi HM. Reintroducing serum FSH measurement during ovarian stimulation for ART. Reprod Biomed Online 2021; 44:548-556. [PMID: 34973935 DOI: 10.1016/j.rbmo.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/08/2021] [Accepted: 10/25/2021] [Indexed: 11/19/2022]
Abstract
RESEARCH QUESTION What is the impact of systemic FSH concentrations during ovarian stimulation for IVF/intracytoplasmic sperm injection on systemic progesterone concentrations in the late follicular phase? DESIGN Post-hoc analysis of a previously performed randomized controlled trial (RCT) performed between November 2017 and February 2020 in a tertiary IVF centre. The RCT included patients with infertility undergoing ovarian stimulation in a gonadotrophin-releasing hormone (GnRH) antagonist protocol. The GnRH antagonist was administered at 08:00 h and recombinant FSH at 20:00 h. Ultrasound and blood tests were performed 3-5 h after the GnRH antagonist. RESULTS The subgroup analysis comprised 105 patients. Systemic FSH concentrations increased from Day 2/3 until initiation of GnRH antagonist and remained constant until the day of trigger (DoT). The total group was split according to the median FSH DoT concentration (12.95 IU/l; Group A <12.95 IU/l; Group B ≥12.95 IU/l). Significant differences, with the higher concentrations in Group B, were found for: systemic FSH concentration on Day 2/3 (P = 0.04), total gonadotrophin dosage (P = 0.03), progesterone on DoT (P = 0.001) and progesterone per follicle (P = 0.004). In the total group, systemic DoT FSH concentration was statistically significantly positively correlated with the DoT progesterone concentration and the ratio of progesterone per follicle (ρ = 0.37 and 0.38, respectively, both P < 0.001). No significant correlations were seen between the systemic DoT FSH concentration and the number of retrieved oocytes. CONCLUSION While ovarian response seems to be independent from the systemic FSH concentrations on the DoT, high concentrations of circulatory FSH augment the production of progesterone.
Collapse
Affiliation(s)
- Barbara Lawrenz
- IVF Department, ART Fertility Clinics, Abu Dhabi, UAE; Women's University Hospital Tuebingen, Tuebingen, Germany.
| | - Laura Melado
- IVF Department, ART Fertility Clinics, Abu Dhabi, UAE
| | - Shieryl Digma
- IVF Department, ART Fertility Clinics, Abu Dhabi, UAE
| | - Junard Sibal
- Clinical Laboratory, ART Fertility Clinics, Abu Dhabi, UAE
| | | | - Claus Yding Andersen
- Laboratory of Reproductive Biology, Section 5712, The Juliane Marie Centre for Women, Children and Reproduction, Copenhagen, University Hospital and Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet Copenhagen, Denmark
| | | |
Collapse
|
5
|
Sasaki LMP, de Carvalho BR, Silva AA, Zaconeta AM, da Silva Wanderley M, da Motta LACR, Lofrano-Porto A. Successful pregnancy after ovulation induction with human chorionic gonadotropin in a woman with selective luteinising hormone deficiency. Hum Reprod 2021; 36:2916-2920. [PMID: 34535998 DOI: 10.1093/humrep/deab213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/30/2021] [Indexed: 11/15/2022] Open
Abstract
Selective LH deficiency has been described in several men, but only in two women who presented normal pubertal development but secondary amenorrhoea due to anovulation. Despite its rarity, this condition represents a valuable model for studying the processes regulated by FSH or LH during late folliculogenesis and ovulation in humans. A woman previously diagnosed with selective LH deficiency due to a homozygous germline splice site mutation in LHB (IVS2 + 1G→C mutation) was submitted to an individualised ovarian induction protocol, first with recombinant LH and then with highly purified urinary hCG. Ovarian follicle growth and ovulation were achieved, and a healthy baby was born after an uneventful term pregnancy. The treatment described herein demonstrates that the clinical actions of exogenous LH or hCG in inducing late-stage follicular development in women with deficient LH production or performance might be interchangeable or inevitable, once FSH-dependent early follicular growth is assured.
Collapse
Affiliation(s)
- Lizandra Moura Paravidine Sasaki
- Department of Women's Health, University Hospital of Brasília, Brasília, Brazil.,Department of Postgraduate Program in Medical Sciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | | | | | - Alberto Moreno Zaconeta
- Department of Women's Health, University Hospital of Brasília, Brasília, Brazil.,Department of Gynecology and Obstetrics, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Miriam da Silva Wanderley
- Department of Gynecology and Obstetrics, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Luiz Augusto Casulari Roxo da Motta
- Department of Postgraduate Program in Medical Sciences, Faculty of Medicine, University of Brasília, Brasília, Brazil.,Department of Endocrinology and Metabolism, University Hospital of Brasília, Brasília, Brazil
| | - Adriana Lofrano-Porto
- Department of Endocrinology and Metabolism, University Hospital of Brasília, Brasília, Brazil.,Department of Molecular Pharmacology Laboratory, Graduate Program in Health Sciences, University of Brasília, Brasília, Brazil
| |
Collapse
|
6
|
Bo W, Zhang N, Wang L, Guo Y, Wu H. Progesterone levels predict pregnancy outcomes in individuals with fallopian tube associated infertility. BMC Pregnancy Childbirth 2021; 21:16. [PMID: 33407250 PMCID: PMC7788974 DOI: 10.1186/s12884-020-03495-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022] Open
Abstract
Background This study aimed at determining the predictive value of human chorionic gonadotropin and progesterone levels on pregnancy outcomes in patients receiving in vitro fertilization due to fallopian tube associated infertility. Methods We retrospectively analyzed the clinical data of 854 cycles due to fallopian tube associated infertility in vitro fertilization fresh embryo transfer. The clinical data had been collected from January 2010 to December 2018 and was divided into 7 groups depending on the progesterone level on human chorionic gonadotropin administration day. Live birth rates and observation trends were calculated. The receiver operating characteristic curve was established to determine the optimal cutoff value for progesterone, which was used to further divide the data into 3 groups; Group 1 (progesterone ≦ 1.0 ng/ml), Group 2 (1.0 ng/ml ≤ progesterone ≤ 1.25 ng/ml), and Group 3 (progesterone ≥ 1.25 ng/ml). We then compared the ovulation results and clinical outcomes among the 3 groups. Results There were no significant differences in age, infertility years, gonadotropin dosage, gonadotropin days, Luteinizing hormone level on human chorionic gonadotropin day, 2 pronuclear fertilization rates, clinical pregnancy rates, live birth rates, full-term birth rate, and preterm birth rates among the three groups. However body mass index (p = 0.001), basal luteinizing hormone (p = 0.034), estrogen peak (p < 0.001), number of oocytes obtained (P < 0.001) were significantly different. Conclusions Progesterone level on human chorionic gonadotropin day does not affect the clinical pregnancy rate and live birth rates after in vitro fertilization. However, progesterone levels between 1.0 and 1.25 ng/ml may lead to good clinical pregnancy outcomes.
Collapse
Affiliation(s)
- Wenjia Bo
- Shandong University of Traditional Chinese Medicine, No. 4655, University Road, University Science and Technology Park, Changqing District, Shandong, 250355, Jinan, China
| | - Ning Zhang
- Shandong University of Traditional Chinese Medicine, No. 4655, University Road, University Science and Technology Park, Changqing District, Shandong, 250355, Jinan, China.
| | - Ling Wang
- Hospital & Institute of Obstetrics and Gynecology Laboratory for Reproductive Immunology , Shanghai Medical College Fudan University , 200433, Shanghai, China.,The Academy of Integrative Medicine , Fudan University , 200433, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases , Shanghai, China
| | - Ying Guo
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine , 250011, Jinan, China
| | - Haicui Wu
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine , 250011, Jinan, China
| |
Collapse
|
7
|
Decleer W, Comhaire F, Balduyck J, Ameye A, Osmanagaoglu K, Devroey P. Replacing HMG/FSH by low-dose HCG to complete corifollitropin alfa stimulation reduces cost per clinical pregnancy: a randomized pragmatic trial. Reprod Biomed Online 2020; 40:468-474. [PMID: 32057673 DOI: 10.1016/j.rbmo.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/09/2019] [Accepted: 10/11/2019] [Indexed: 11/25/2022]
Abstract
RESEARCH QUESTION The cost of IVF treatment remains high, among other factors because of the medication needed for ovarian stimulation. This study investigated the effect of using low-dose human chorionic gonadotrophin (HCG) for the second phase of follicular maturation after corifollitropin alfa induction, to replace the more expensive, either recombinant or human menopausal gonadotrophin (HMG), on the cost of ovarian stimulation. DESIGN One hundred and five patients were randomly divided into two groups: patients in the HCG group (n = 50) received low-dose HCG from Day 7 until the diameter of at least three follicles reached 17 mm or more, while patients in the FSH group (n = 55) received conventional ovarian stimulation with highly purified HMG injections. RESULTS The clinical pregnancy rate in the HCG group was 38% higher than in the FSH group (number needed to treat, NNT = 13). The cost per pregnancy needed for ovarian stimulation was reduced from €4902 in the FSH group to €2684 in the HCG group. Hence, the cost of ovarian stimulation medication to obtain 10 pregnancies using the conventional FSH protocol is sufficient to attain 18 pregnancies when applying the low-dose HCG protocol. CONCLUSION This study provides evidence that using HCG instead of HMG/FSH for ovarian stimulation results in a significant reduction in the cost of IVF with, at least, an equivalent pregnancy rate.
Collapse
Affiliation(s)
- Wim Decleer
- Fertility Clinic, Weststraat 16-18, Aalter 9880, Belgium; IVF Center, AZ Jan Palfijn Gent, Watersportlaan 5, Gent 9000, Belgium.
| | - Frank Comhaire
- Fertility Clinic, Weststraat 16-18, Aalter 9880, Belgium
| | | | - Alice Ameye
- KU Leuven, Oude Markt 13, Leuven 3000, Belgium
| | - Kaan Osmanagaoglu
- IVF Center, AZ Jan Palfijn Gent, Watersportlaan 5, Gent 9000, Belgium
| | - Paul Devroey
- Fertility Clinic, Weststraat 16-18, Aalter 9880, Belgium; Center for Reproductive Medicine, UZ Brussel, Laarbeeklaan 101, Jette 1090, Belgium
| |
Collapse
|
8
|
Pituitary Hormones (FSH, LH, PRL, and GH) Differentially Regulate AQP5 Expression in Porcine Ovarian Follicular Cells. Int J Mol Sci 2019; 20:ijms20194914. [PMID: 31623386 PMCID: PMC6801619 DOI: 10.3390/ijms20194914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 12/27/2022] Open
Abstract
This study aimed to examine the effect of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), and growth hormone (GH) on Aquaporin 5 (AQP5) expression in granulosa (Gc) and theca cells (Tc) from medium (MF) and large (LF) ovarian follicles of pigs. The results showed that GH significantly decreased the expression of AQP5 in Gc from MF in relation to the control. In the Gc of large follicles, PRL stimulated the expression of AQP5. However, the increased expression of AQP5 in the Tc of LF was indicated by GH and PRL in relation to the control. A significantly higher expression of the AQP5 protein in the Gc from MF and LF was indicated by FSH and PRL. In co-cultures, an increased expression of AQP5 was observed in the Gc from LF incubated with LH, PRL, and GH. A significantly increased expression of AQP5 was also observed in co-cultures of Tc from all type of follicles incubated with LH, whereas PRL stimulated the expression of AQP5 in Tc from MF. Moreover, AQP5 protein expression increased in the co-culture isolated from MF and LF after treatment with FSH, LH, PRL, and GH. AQP5 immunoreactivity was observed in the cytoplasm, mainly in the perinuclear region and endosomes, as well as in the cell membranes of Gc and Tc from the LF and MF.
Collapse
|
9
|
Tayyar AT, Kahraman S. Comparison between cycles of the same patients when using recombinant luteinizing hormone + recombinant follicle stimulating hormone (rFSH), human menopausal gonadotropin + rFSH and rFSH only. Arch Med Sci 2019; 15:673-679. [PMID: 31110533 PMCID: PMC6524176 DOI: 10.5114/aoms.2017.72408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/11/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Recombinant follicle stimulating hormone (rFSH), recombinant luteinizing hormone (rLH), and urinary human menopausal gonadotropin (uHMG) are widely used for controlled ovarian stimulation (COS). This study compares the effects of rFSH only, rLH + rFSH, and HMG + rFSH administration on in vitro fertilization (IVF) outcomes for patients in three different yearly follow-up cycles. MATERIAL AND METHODS This retrospective, single-center cohort study was conducted from January 2001 to June 2016 at Istanbul Memorial Hospital, Artificial Reproductive Technology Center. From a total of 27,024 IVF cycles in women aged 18 to 45 years (17,536 rFSH only; 2147 rLH + rFSH; 7341 HMG + rFSH), the results of 2,147 cycles receiving a treatment of rLH + rFSH over the 3-year evaluation and 2,081 total cycles in which rLH + rFSH was used at least once were evaluated, and different gonadotropin combinations were compared. RESULTS The age and body mass index of the patients in the uHMG + rFSH group were found to be significantly higher than those of the patients in the rLH + rFSH and rFSH only groups (p < 0.001). The total gonadotropin (GND) dosage of the patients in the rLH + rFSH group was found to be significantly lower than that of the HMG + rFSH group (p = 0.001). No statistically significant differences were found between the clinical and ongoing pregnancy rates, while the highest clinical and ongoing pregnancy rate was observed in the rLH + rFSH group at age 35-39 years. CONCLUSIONS Recombinant luteinizing hormone administration may increase the number of clinical pregnancies for patients aged 35-39 years.
Collapse
Affiliation(s)
- Ahter Tanay Tayyar
- Department of Obstetrics and Gynecology, Health Sciences University Zeynep Kamil Maternity and Children’s Research Hospital, Istanbul, Turkey
| | - Semra Kahraman
- Department of Assisted Reproductive Technologies and Reproductive Genetics, Istanbul Memorial Hospital, Istanbul, Turkey
| |
Collapse
|
10
|
Evaluation of the Second Follicular Wave Phenomenon in Natural Cycle Assisted Reproduction: A Key Option for Poor Responders through Luteal Phase Oocyte Retrieval. ACTA ACUST UNITED AC 2019; 55:medicina55030068. [PMID: 30875815 PMCID: PMC6473900 DOI: 10.3390/medicina55030068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/08/2019] [Accepted: 03/06/2019] [Indexed: 12/24/2022]
Abstract
Background: Emergence of Luteal Phase Oocyte Retrieval (LuPOR) may revolutionize the practice regarding the time-sensitive nature of poor responders ascertaining a higher number of oocytes, in a shorter amount of time. This may be especially important in view of employing the approach of natural cycles for Poor Responders. We suggest the acronym LuPOR describing the clinical practice of luteal phase oocyte retrieval. The aim of the study is to offer insight regarding the identity of LuPOR, and highlight how this practice may improve management of the special subgroup of poor responders. Materials and Methods: The present retrospective observational clinical study includes the collection and statistical analysis of data from 136 poor responders who underwent follicular oocyte retrieval (FoPOR) and subsequent LuPOR in natural cycles, during their In Vitro Fertilization (IVF) treatment, from the time period of 2015 to 2018. All 136 participants were diagnosed with poor ovarian reserve (POR) according to Bologna criteria. The 272 cycles were categorized as follows: 136 natural cycles with only FoPORs (Control Group) and 136 natural cycles including both FoPORs and LuPORs. Results: Our primary results indicate no statistically significant differences with regards to the mean number of oocytes, the maturation status, and fertilization rate between FoPOR and LuPOR in natural cycles. Secondarily, we demonstrate a statistically significant higher yield of oocytes (2.50 ± 0.78 vs. 1.25 ± 0.53), better oocyte maturity status (1.93 ± 0.69 vs. 0.95 ± 0.59) and higher fertilization rate (1.31 ± 0.87 vs. 0.61 ± 0.60) in natural cycles including both FoPOR and LuPOR, when compared to cycles including only FoPOR. Conclusion: Our study may contribute towards the establishment of an efficient poor responders’ management through the natural cycle approach, paving a novel clinical practice and ascertaining the opportunity to employ oocytes and embryos originating from a luteal phase follicular wave.
Collapse
|
11
|
Zhu X, Fu Y. Randomized, Controlled Pilot Study of Low-Dose Human Chorionic Gonadotropin Administration Beginning From the Early Follicular Phase for Women With Polycystic Ovarian Syndrome Undergoing Ovarian Stimulation Using the Progesterone Protocol. Front Endocrinol (Lausanne) 2019; 10:875. [PMID: 31920984 PMCID: PMC6923733 DOI: 10.3389/fendo.2019.00875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/29/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose: To illustrate whether low-dose human chorionic gonadotropin (hCG) administration during the early follicular phase could reduce the number of large preovulatory follicles in women with polycystic ovarian syndrome (PCOS) undergoing ovarian stimulation using the progesterone protocol. Methods: We performed a randomized, controlled pilot trial at a university-affiliated tertiary hospital. A total of 40 infertile women undergoing their first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment with the freeze-all strategy were included. Human menopausal gonadotropin (hMG) and progesterone soft capsule 100 mg/d were added simultaneously beginning from menstrual cycle day 3 for all participants. Low-dose hCG (200 IU) was injected every 3 days in the study group from the first day of ovarian stimulation until trigger. The primary outcome was the number of large preovulatory follicles. Secondary outcomes included the incidence of ovarian hyperstimulation syndrome (OHSS); the number of oocytes retrieved, mature oocytes, and good-quality embryos; and clinical results after frozen-thawed embryo transfer (FET) cycles. Results: The study group had slightly more large preovulatory follicles than the control group (17.75 ± 10 vs. 13.2 ± 5.34; P > 0.05). None of the participants experienced severe OHSS. There were no statistically significant differences in the number of oocytes retrieved (15.9 ± 8.46 vs. 15.75 ± 6.96), mature oocytes (13.55 ± 6.56 vs. 13.4 ± 6.34), and good-quality embryos (5.5 ± 3.41 vs. 4.9 ± 2.99) between the two groups (P > 0.05). Clinical pregnancy rates (65.52 vs. 41.94%; P = 0.067) and live birth rates (48.28 vs. 35.48%; P = 0.315) per transfer following FET of the study group were higher than those of the control group, but without statistical significance. Conclusions: Administration of low-dose hCG from the early follicular phase for PCOS patients undergoing ovarian stimulation with progesterone protocol may lead to slightly more early preovulatory follicles and marginally, but not significantly, higher clinical pregnancy rates. A continuous trial should be performed to explore the effects of supplementation with different doses of hCG from the start of ovarian stimulation in PCOS patients using the progesterone protocol. Clinical Trial Registration: Chictr.org.cn, identifier: ChiCTR-IOR-15007165.
Collapse
|
12
|
Pituitary Gonadotropins, Prolactin and Growth Hormone Differentially Regulate AQP1 Expression in the Porcine Ovarian Follicular Cells. Int J Mol Sci 2017; 19:ijms19010005. [PMID: 29267208 PMCID: PMC5795957 DOI: 10.3390/ijms19010005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/16/2017] [Accepted: 12/16/2017] [Indexed: 01/28/2023] Open
Abstract
The present in vitro study analyzed whether the hormones that affect the ovarian follicular steroidogenesis process also participate in the regulation of AQP1 mRNA and protein expression. Granulosa (Gc) and theca cells (Tc) of medium and large porcine ovarian follicles were exposed to follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL) and growth hormone (GH) for 24 h in separated cells and co-cultures of these cells. Real-time PCR, Western blotting, immunofluorescence and volumetric analysis were then performed. Gonadotropins, PRL and GH had a stimulatory impact on AQP1 mRNA and protein expression in Gc and Tc of medium and large ovarian cells. Moreover, swelling assays, in response to a hypotonic environment, demonstrated the functional presence of AQPs in porcine Gc and Tc. Immunofluorescence analysis showed that AQP1 protein was mainly localized in the perinuclear region of the cytoplasm, endosomes and cell membranes of Gc and Tc from medium and large follicles. It seems possible that AQP1 present in Gc and Tc cells may be implicated not only in the regulation of water homeostasis required for follicle development but also in cell proliferation and migration.
Collapse
|
13
|
Luciano AM, Sirard MA. Successful in vitro maturation of oocytes: a matter of follicular differentiation. Biol Reprod 2017; 98:162-169. [DOI: 10.1093/biolre/iox149] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/17/2017] [Indexed: 01/08/2023] Open
Affiliation(s)
- Alberto Maria Luciano
- Reproductive and Developmental Biology Laboratory, Department of Health, Animal Sciences and Food Safety, University of Milan, Milan, Italy
| | - Marc-André Sirard
- Centre de Recherche en reproduction, Développement et Santé Intergénérationnelle, Département des Sciences Animales, Université Laval, Québec, Québec, Canada
| |
Collapse
|
14
|
Ho JR, Paulson RJ. Modified natural cycle in in vitro fertilization. Fertil Steril 2017; 108:572-576. [DOI: 10.1016/j.fertnstert.2017.08.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
|
15
|
Wang AC, Wang Y, Wu FX, Zhu DY. Assessing predictors for the success of GnRH antagonist protocol in reproductive women in IVF/ICSI - in fresh cycles. Biomed Rep 2017; 7:482-486. [PMID: 29181162 DOI: 10.3892/br.2017.984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/06/2017] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to evaluate the factors that affect the success rate of gonadotropin-releasing hormone antagonist on in vitro fertilization/intracytoplasmic sperm injection cycles. Multivariate analysis was performed to assess the factors that influence the outcomes, such as oocytes retrieved, and the success of pregnancy. The results showed that E2, P on human chorionic gonadotropin (HCG) day and body mass index (BMI) were positively correlated with the number of oocytes retrieved (P=0.001, P=0.024, P=0.017, respectively). The duration of infertility as well as the luteinizing hormone on HCG day were negatively correlated with the number of oocytes (P=0.048, P=0.002, respectively). The age of the women and P on HCG day were negatively correlated with successful pregnancy (P<0.001, P=0.022). In conclusion, some parameters, such as E2, P, and LH on the HCG day, as well as age and BMI, may affect treatment outcomes.
Collapse
Affiliation(s)
- An-Cong Wang
- Department of Reproductive Medicine, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China.,Department of Obstetrics and Gynecology, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Ying Wang
- Department of Gynecologic Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong 250117, P.R. China
| | - Feng-Xia Wu
- Department of Anatomy, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Dong-Yi Zhu
- Department of Reproductive Medicine, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China.,Department of Obstetrics and Gynecology, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| |
Collapse
|
16
|
Paulson RJ. Introduction: Contemporary approaches to alternative ovarian stimulation strategies for in vitro fertilization. Fertil Steril 2017; 108:555-557. [PMID: 28911928 DOI: 10.1016/j.fertnstert.2017.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
In the current practice of IVF, the vast majority of cycles use some form of controlled ovarian stimulation before egg retrieval to increase the number of embryos available for transfer or cryopreservation. However, the optimal stimulation regimen has not been established. This month's Views and Reviews presents five different approaches to alternative ovarian stimulation strategies. These include mild stimulation regimens, modified natural cycles, stimulation with oral agents, in vitro maturation (in the absence of stimulation), and finally, a proposal for patient-tailored ovarian stimulation. As the treatment of infertility becomes more personalized, it is likely that standard, heavy-handed stimulation protocols will give way to simpler strategies, specifically tailored to each patient's individual characteristics and needs.
Collapse
Affiliation(s)
- Richard J Paulson
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, California.
| |
Collapse
|
17
|
Burks HR, Baker M, Quaas AM, Bendikson KA, Chung K, Paulson RJ. The dilemma of counseling patients about poor prognosis: live birth after IVF with autologous oocytes in a 43-year-old woman with FSH levels above 30 mIU/mL. J Assist Reprod Genet 2017; 34:1185-1188. [PMID: 28656538 DOI: 10.1007/s10815-017-0986-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/16/2017] [Indexed: 10/19/2022] Open
Abstract
Providing reasonable expectations to patients with diminished ovarian reserve prior to attempting pregnancy through in vitro fertilization (IVF) is one of the most challenging aspects of fertility care. In some instances, advice from the clinician to pursue more effective treatment, such as donor oocytes, may not be acceptable to the patient. In this case report, a patient is presented who represents a poor prognosis candidate for IVF treatment. She was 43 years old with six prior failed IVF cycles and repetitive basal FSH values above 30 mIU/mL. Presented are the challenges in patient counseling and decision making. In her seventh IVF cycle, which she was strongly counseled against pursuing, the patient experienced the desired outcome of live birth. Increasing reports are emerging of live birth using autologous oocytes among women of advanced reproductive age. These instances, as well as the case of our patient, raise issues commonly encountered in patient counseling in poor prognosis patients. This discussion should include an emphasis on patient goals as well as an acknowledgement that no test for ovarian reserve has a 100% positive predictive value.
Collapse
Affiliation(s)
- Heather R Burks
- Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology and Infertility, University of Oklahoma Health Sciences Center, PO Box 26901, COMB 2400, Oklahoma City, OK, 73126, USA.
| | - Marsha Baker
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Kaiser Permanente, Los Angeles, CA, USA
| | - Alexander M Quaas
- Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology and Infertility, University of Oklahoma Health Sciences Center, PO Box 26901, COMB 2400, Oklahoma City, OK, 73126, USA.,Universitätsspital Basel Frauenklinik, Spitalstr. 21, 4031, Basel, Switzerland
| | - Kristin A Bendikson
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Southern California, 2020 Zonal Ave, Room 534, Los Angeles, CA, 90033, USA
| | - Karine Chung
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Southern California, 2020 Zonal Ave, Room 534, Los Angeles, CA, 90033, USA
| | - Richard J Paulson
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Southern California, 2020 Zonal Ave, Room 534, Los Angeles, CA, 90033, USA
| |
Collapse
|
18
|
Human Chorionic Gonadotropin: The Pregnancy Hormone and More. Int J Mol Sci 2017; 18:ijms18051059. [PMID: 28505106 PMCID: PMC5454971 DOI: 10.3390/ijms18051059] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/03/2017] [Accepted: 05/10/2017] [Indexed: 01/10/2023] Open
Abstract
To thoroughly review the uses of human chorionic gonadotropin (hCG) related to the process of reproduction and also assess new, non-traditional theories. Review of the international literature and research studies. hCG and its receptor, LH/CGR, are expressed in numerous sites of the reproductive tract, both in gonadal and extra-goanadal tissues, promoting oocyte maturation, fertilization, implantation and early embryo development. Moreover, hCG seems to have a potential role as an anti-rejection agent in solid organ transplantation. Future research needs to focus extensively on the functions of hCG and its receptor LH/CGR, in an effort to reveal known, as well as unknown clinical potentials.
Collapse
|
19
|
Iaconelli CAR, Setti AS, Braga DPAF, Maldonado LGL, Iaconelli A, Borges E, Aoki T. Concomitant use of FSH and low-dose recombinant hCG during the late follicular phase versus conventional controlled ovarian stimulation for intracytoplasmic sperm injection cycles. HUM FERTIL 2017; 20:285-292. [PMID: 28325095 DOI: 10.1080/14647273.2017.1303197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The objective of this study was to investigate the effects of low-dose hCG supplementation on ICSI outcomes and controlled ovarian stimulation (COS) cost. Three hundred and thirty patients undergoing ICSI were split into groups according to the COS protocol: (i) control group (n = 178), including patients undergoing conventional COS treatment; and (ii) low-dose hCG group (n = 152), including patients undergoing COS with low-dose hCG supplementation. Lower mean total doses of FSH administered and higher mean oestradiol level and mature oocyte rates were observed in the low-dose hCG group. A significantly higher fertilization rate, high-quality embryo rate and blastocyst formation rate were observed in the low-dose hCG group as compared to the control group. The miscarriage rate was significantly higher in the control group compared to the low-dose hCG group. A significantly lower incidence of OHSS was observed in the low-dose hCG group. There was also a significantly lower gonadotropin cost in the low-dose hCG group as compared to the control group ($1235.0 ± 239.0×$1763.0 ± 405.3, p < 0.001). The concomitant use of low-dose hCG and FSH results in a lower abortion rate and increased number of mature oocytes retrieved, as well as improved oocyte quality, embryo quality and blastocyst formation and reduced FSH requirements.
Collapse
Affiliation(s)
- Carla Andrade Rebello Iaconelli
- a Fertility Medical Group, clinical department ; Sao Paulo , SP , Brazil.,b Faculdade de Ciências Médicas da Santa Casa de São Paulo, health sciences department ; Sao Paulo , SP , Brazil
| | - Amanda Souza Setti
- b Faculdade de Ciências Médicas da Santa Casa de São Paulo, health sciences department ; Sao Paulo , SP , Brazil.,c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil
| | - Daniela Paes Almeida Ferreira Braga
- c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil.,e Disciplina de Urologia, Area de Reproducão Humana, Departamento de Cirurgia , Universidade Federal de São Paulo , Sao Paulo , SP , Brazil
| | | | - Assumpto Iaconelli
- a Fertility Medical Group, clinical department ; Sao Paulo , SP , Brazil.,c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil
| | - Edson Borges
- a Fertility Medical Group, clinical department ; Sao Paulo , SP , Brazil.,c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil
| | - Tsutomu Aoki
- b Faculdade de Ciências Médicas da Santa Casa de São Paulo, health sciences department ; Sao Paulo , SP , Brazil
| |
Collapse
|
20
|
Vanni VS, Viganò P, Quaranta L, Pagliardini L, Giardina P, Molgora M, Munaretto M, Candiani M, Papaleo E. Are extremely high progesterone levels still an issue in IVF? J Endocrinol Invest 2017; 40:69-75. [PMID: 27568185 DOI: 10.1007/s40618-016-0531-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Premature luteinization of one or more developing follicles complicates 1-2 % of controlled ovarian stimulation cycles for assisted reproduction. The management of this complication is controversial, with cycle cancellation likely representing the most commonly used strategy. The aim of this study was to evaluate the efficacy of the "freeze-all" policy-where the entire cohort of blastocysts is cryopreserved for subsequent frozen-thawed embryo transfer-in treating cases of premature luteinization. METHODS Patients experiencing premature luteinization during controlled ovarian stimulation-identified by extremely high progesterone levels at induction (P levels ≥3.0 ng/ml and/or P/estradiol ratio ≥1, n = 42)-were included in a "freeze-all" program and compared to controls undergoing a "freeze-all" program with normal progesterone levels at induction (P < 1.5 ng/ml, n = 67). RESULTS Blastulation rate was comparable between patients with premature luteinization and controls (48.1 ± 20.5 % in Cases vs. 52.3 ± 24.9 % in Controls, p = 0.36). Ongoing pregnancy rates after the first frozen-thawed embryo transfer (38.1 % in Cases and 41.0 % in Controls, p = 0.83) and cumulative ongoing pregnancy rates after three frozen-thawed embryo transfer cycles (40.5 % in Cases vs. 47.8 % in Controls, p = 0.55) were also similar. CONCLUSIONS These results show that extremely marked progesterone elevation throughout controlled ovarian stimulation does not impair blastocyst development and implantation potential in the context of a "freeze-all" strategy. Based on this, adoption of the "freeze-all" strategy represents a valuable tool in treating premature luteinization. In contrast, cycle cancellation-likely the most frequently used method for management of this complication-currently represents a misconduct.
Collapse
Affiliation(s)
- V S Vanni
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - P Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - L Quaranta
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - L Pagliardini
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - P Giardina
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - M Molgora
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - M Munaretto
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - M Candiani
- Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy
| | - E Papaleo
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20136, Milan, Italy.
| |
Collapse
|
21
|
Hu KL, Zhao H, Chang HM, Yu Y, Qiao J. Kisspeptin/Kisspeptin Receptor System in the Ovary. Front Endocrinol (Lausanne) 2017; 8:365. [PMID: 29354093 PMCID: PMC5758547 DOI: 10.3389/fendo.2017.00365] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/13/2017] [Indexed: 12/26/2022] Open
Abstract
Kisspeptins are a family of neuropeptides that are critical for initiating puberty and regulating ovulation in sexually mature females via the central control of the hypothalamic-pituitary-gonadal axis. Recent studies have shown that kisspeptin and its receptor kisspeptin receptor (KISS1R) are expressed in the mammalian ovary. Convincing evidence indicates that kisspeptins can activate a wide variety of signals via its binding to KISS1R. Experimental data gathered recently suggest a putative role of kisspeptin signaling in the direct control of ovarian function, including follicular development, oocyte maturation, steroidogenesis, and ovulation. Dysregulation or naturally occurring mutations of the kisspeptin/KISS1R system may negatively affect the ovarian function, leading to reproductive pathology or female infertility. A comprehensive understanding of the expression, actions, and underlying molecular mechanisms of this system in the human ovary is essential for novel approaches to therapeutic and diagnostic interventions in reproductive diseases and infertility.
Collapse
Affiliation(s)
- Kai-Lun Hu
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology and Key Laboratory of Assisted Reproduction, Ministry of Education, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Hongcui Zhao
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology and Key Laboratory of Assisted Reproduction, Ministry of Education, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- *Correspondence: Hongcui Zhao, ; Yang Yu,
| | - Hsun-Ming Chang
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology and Key Laboratory of Assisted Reproduction, Ministry of Education, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yang Yu
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology and Key Laboratory of Assisted Reproduction, Ministry of Education, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- *Correspondence: Hongcui Zhao, ; Yang Yu,
| | - Jie Qiao
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology and Key Laboratory of Assisted Reproduction, Ministry of Education, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| |
Collapse
|
22
|
Can we modify assisted reproductive technology practice to broaden reproductive care access? Fertil Steril 2016; 105:1138-1143. [DOI: 10.1016/j.fertnstert.2016.03.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/20/2016] [Accepted: 03/04/2016] [Indexed: 12/15/2022]
|
23
|
Low-dose human chorionic gonadotropin alone can complete follicle maturity: successful application to modified natural cycle in vitro fertilization. Fertil Steril 2016; 105:1228-1231. [DOI: 10.1016/j.fertnstert.2016.01.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/31/2015] [Accepted: 01/16/2016] [Indexed: 12/16/2022]
|
24
|
Andersen CY. Grand Challenges in Reproductive Endocrinology. Front Endocrinol (Lausanne) 2016; 7:169. [PMID: 28228746 PMCID: PMC5297419 DOI: 10.3389/fendo.2016.00169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/14/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Claus Yding Andersen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, Copenhagen University Hospital, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Claus Yding Andersen,
| |
Collapse
|
25
|
Andersen CY, Elbaek HO, Alsbjerg B, Laursen RJ, Povlsen BB, Thomsen L, Humaidan P. Daily low-dose hCG stimulation during the luteal phase combined with GnRHa triggered IVF cycles without exogenous progesterone: a proof of concept trial. Hum Reprod 2015. [DOI: 10.1093/humrep/dev184] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
26
|
Li PF, Zhu H, Tan L, Zhao DM, Ma LY, Xiang YG, Zhang D, Dou Q, Lu N. Effects of high progesterone on outcomes of in vitro fertilization-embryo transfer in patients with different ovarian responses. Syst Biol Reprod Med 2015; 61:161-7. [PMID: 25915151 DOI: 10.3109/19396368.2015.1033779] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The data of 3,841 cycles undergoing in vitro fertilization-embryo transfer (IVF-ET) in our reproductive Center between January 2003 and December 2013 were retrospectively analyzed. According to the number of oocytes retrieved, this study was divided into the high ovarian response group (oocyte retrieval≥20, 842 cycles), the moderate ovarian response group (5<oocyte retrieval<20, 2008 cycles), and the low ovarian response group (oocyte retrieval≤5, 991 cycles). The treatment outcomes were compared between the patients with an increased progesterone (P) level and the patients where the P level did not increase. With increase in ovarian response, the cut-off values of serum P on the day of human chorionic gonadotrophin (hCG) rose, and respectively were 2.5 ng/ml in the high ovarian response group, 2.25 ng/ml in the moderate ovarian response group, and 1.5 ng/ml in the low ovarian response group. In each group, the clinical pregnancy rate and embryo implantation rate were lower in the patients with an increased P level compared to those where the P level did not increase (all p<0.05). However, there were no significant difference in the fertilization rate, cleavage rate, and high-quality embryo rate (all p>0.05). The increased level of P on the day of hCG may affect the treatment outcomes of IVF-ET. The cut-off values of serum P seem to be associated with ovarian response. Increased ovarian response causes the cut-off values of serum P to rise.
Collapse
Affiliation(s)
- Peng-fen Li
- Reproductive Medical Center, Second Affiliated Hospital of Zhengzhou University , Zhengzhou , China
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
INTRODUCTION Assisted reproduction techniques are the frequent treatment of infertility. Despite the advances in science and technology, the management of poor responder patients is still considered as one of the most urgent problems. The lack of unified definition makes the management of the poor responder patients very difficult. The aim of this review is to examine and compare the different studies done about the problem of poor responder patients. METHODS On an online research of MEDLINE/PUBMED, we found several studies on pharmacological treatment for poor responders' patients. RESULTS Our review shows that in the years numerous therapies for the management of these patients who do not respond to ovarian stimulation have been evaluated and studied, but the main problem is the large and still not well-defined meaning of poor responder women. CONCLUSION The management of the poor responder patients is very difficult. Currently, there is no any standard treatment for poor responder patients. Considering the importance of the problem, it is important to identify a diagnostic and therapeutic target. Our review shows that there are many studies with different therapeutic approaches which deserve further in-depth study to standardize diagnostic and therapeutic target.
Collapse
Affiliation(s)
- V Giovanale
- Department of Gynecologic-Obstetrical Sciences and Urological Sciences, University of Rome Sapienza, Sant'Andrea Hospital , Rome , Italy
| | | | | | | | | |
Collapse
|
28
|
Patrizio P, Vaiarelli A, Levi Setti PE, Tobler KJ, Shoham G, Leong M, Shoham Z. How to define, diagnose and treat poor responders? Responses from a worldwide survey of IVF clinics. Reprod Biomed Online 2015; 30:581-92. [PMID: 25892496 DOI: 10.1016/j.rbmo.2015.03.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 02/26/2015] [Accepted: 03/03/2015] [Indexed: 01/14/2023]
Abstract
Poor responders represent a significant percentage of couples treated in IVF units (10-24%), but the standard definition of poor responders remains uncertain and consequently optimal treatment options remain subjective and not evidence-based. In an attempt to provide uniformity on the definition, diagnosis and treatment of poor responders, a worldwide survey was conducted asking IVF professionals a set of questions on this complex topic. The survey was posted on www.IVF-worldwide.com, the largest and most comprehensive IVF-focused website for physicians and embryologists. A total of 196 centres replied, forming a panel of IVF units with a median of 400 cycles per year. The present study shows that the definition of poor responders is still subjective, and many practices do not use evidence-based treatment for this category of patients. Our hope is that by leveraging the great potential of the internet, future studies may provide immediate large-scale sampling to standardize both poor responder definition and treatment options.
Collapse
Affiliation(s)
| | - Alberto Vaiarelli
- Centre for Reproductive Medicine, Vrije University Brussels, Belgium
| | - Paolo E Levi Setti
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Humanitas Research Hospital Fertility Center, Rozzano, Milan 20084, Italy
| | - Kyle J Tobler
- Department of Gynecology and Obstetrics, Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gon Shoham
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Zeev Shoham
- Department of Obstetrics and Gynaecology, Kaplan Medical Center, Rehovot, Israel; Hadassah Medical School, Jerusalem, Israel
| |
Collapse
|
29
|
Choi J, Smitz J. Luteinizing hormone and human chorionic gonadotropin: a review of their varied clinical applications in assisted reproductive technology. Expert Rev Endocrinol Metab 2015; 10:87-100. [PMID: 30289044 DOI: 10.1586/17446651.2015.969711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Luteinizing hormone (LH) and human chorionic gonadotropin (hCG) are often viewed as interchangeable from a functional standpoint because they are highly homologous members of the same glycoprotein hormone family that share a common α-subunit and receptor. However, technological advances yielding highly purified and recombinant gonadotropin preparations have revealed that LH and hCG fulfill different roles, both endogenously and when administered exogenously. These differences are becoming more apparent as the individual hormones are incorporated into the treatment of infertility - a therapeutic area that is continually advancing with the introduction of new agents and emerging clinical trial data. This review examines the unique attributes of LH and hCG that drive their distinctive applications in the treatment of female infertility.
Collapse
Affiliation(s)
- Janet Choi
- a 1 The Center for Women's Reproductive Care at Columbia University, 1790 Broadway, 2nd Floor, New York, NY 10019, USA
| | - Johan Smitz
- b 2 Laboratory Hormonology and Tumormarkers, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| |
Collapse
|
30
|
Abstract
In contrast to current approaches, the aim of mild stimulation is to develop safer and more patient-friendly protocols in which the risks of the treatment as a whole are minimized. Mild stimulation is defined as the method when exogenous gonadotropins are administered at lower doses, and/or for a shorter duration in GnRH antagonist co-treated cycles, or when oral compounds (antiestrogens, aromatase inhibitors) are used for ovarian stimulation for IVF, with the aim of limiting the number of oocytes obtained to fewer than eight. In this chapter we discuss the relevant physiology of follicle development, the development of milder stimulation protocols, the implications of mild stimulation, the current state of affairs, and future developments.
Collapse
Affiliation(s)
- O Hamdine
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CS, Utrecht, The Netherlands
| | | | | |
Collapse
|
31
|
Santos-Ribeiro S, Polyzos N, Haentjens P, Smitz J, Camus M, Tournaye H, Blockeel C. Live birth rates after IVF are reduced by both low and high progesterone levels on the day of human chorionic gonadotrophin administration. Hum Reprod 2014; 29:1698-705. [DOI: 10.1093/humrep/deu151] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
32
|
Serum estradiol level change after human chorionic gonadotropin administration had no correlation with live birth rate in IVF cycles. Eur J Obstet Gynecol Reprod Biol 2014; 178:177-82. [PMID: 24862918 DOI: 10.1016/j.ejogrb.2014.02.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 01/05/2014] [Accepted: 02/26/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the correlation between the estradiol (E2) level change after hCG administration and the live birth rate in GnRH agonist long or short protocols, and to explore the possible factors related to E2 dynamics after hCG administration during controlled ovarian hyperstimulation (COH). STUDY DESIGN A retrospective analysis was performed on 2868 patients who received IVF/intracytoplasmic sperm injection (ICSI) treatment with GnRH agonist long or short protocol. The patients were divided into three groups according to their serum E2 changes after hCG administration, and the live birth rates were compared among groups. The area under the receiver operating characteristic (ROC) curve was calculated to assess the predictive value of E2 change for the probability of live birth. Logistic regression analysis was also applied to exclude interference from various confounding factors. Finally, multivariate regression analysis was conducted to assess factors related to the E2 change after hCG administration. RESULTS No significant difference was observed in live birth rates (4.26%, 36.38% or 30.81% in long protocol (P=0.697); 25.81%, 26.71% or 30.81% in short protocol (P=0.697)) among patients with increasing, plateauing or decreasing E2 responses after hCG administration. The area under the ROC curve for the E2 change in prediction of live birth rate was 0.506 in long protocol, or 0.524 in short protocol. Logistic regression analysis showed that the serum E2 change after hCG administration had no correlation with live birth rate. Multivariate regression analysis showed that the percentage of mature follicles (larger than 14mm) and the duration of stimulation negatively correlated with the E2 change after hCG administration. CONCLUSIONS In GnRH agonist cycles, the serum E2 change after hCG administration had no correlation with live birth rate in fresh embryo transfer cycles, and this change negatively correlated with the percentage of mature follicles on the day of hCG administration.
Collapse
|
33
|
Dahan MH, Agdi M, Shehata F, Son W, Tan SL. A comparison of outcomes from in vitro fertilization cycles stimulated with either recombinant luteinizing hormone (LH) or human chorionic gonadotropin acting as an LH analogue delivered as human menopausal gonadotropins, in subjects with good or poor ovarian reserve: a retrospective analysis. Eur J Obstet Gynecol Reprod Biol 2013; 172:70-3. [PMID: 24314801 DOI: 10.1016/j.ejogrb.2013.10.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 10/10/2013] [Accepted: 10/27/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare rates of pregnancy and IVF parameters in subjects who were stimulated with FSH plus recombinant human luteinizing hormone or menopausal gonadotropins. To determine whether responses to type of LH differ in poor or good responders. STUDY DESIGN Retrospective analysis at a university-based fertility center. Subjects were women with good and poor ovarian reserve, who underwent in vitro fertilization during a 2 year period, as part of a long agonist (N=122), or microdose flair (N=79) protocol. Measurements included FSH and LH dose, number of oocytes collected, number of embryos obtained, and pregnancy and clinical pregnancy rates. RESULTS Patients treated with r-hLH (n=105) had higher numbers of eggs retrieved and of embryos while using less FSH than their hMG-treated (n=96) counterparts. Pregnancy and clinical pregnancy rates were significantly higher with r-hLH than with hMG protocols (p=0.008 and 0.009, respectively). If patients had a baseline serum FSH level ≥10IU/L, clinical pregnancy rates were higher when r-hLH was used. When the antral follicle count was below 6 no significant differences in stimulation parameters or outcomes were detected between the groups. CONCLUSION r-hLH may be beneficial when compared to hMG and used for in-vitro fertilization, except in subjects with baseline follicle counts less than 6. Further data should be obtained.
Collapse
Affiliation(s)
- Michael H Dahan
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada.
| | - Mohammed Agdi
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
| | - Fady Shehata
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
| | - Weonyoung Son
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
| | - Seang Lin Tan
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
| |
Collapse
|
34
|
Thuesen LL, Smitz J, Loft A, Nyboe Andersen A. Endocrine effects of hCG supplementation to recombinant FSH throughout controlled ovarian stimulation for IVF: a dose-response study. Clin Endocrinol (Oxf) 2013; 79:708-15. [PMID: 23448396 DOI: 10.1111/cen.12186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 02/13/2013] [Accepted: 02/19/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To analyse the endocrine response in relation to the Δ-4 and Δ-5 pathways of ovarian steroidogenesis after different doses of human chorionic gonadotrophin (hCG) supplementation to recombinant FSH from Day 1 of controlled ovarian stimulation for IVF. DESIGN A randomized dose-response pilot study. PATIENTS A total of 62 IVF patients aged 25-37 years with regular cycles and FSH <12 IU/l were treated with a fixed dose of rFSH 150 IU/day and randomized to four hCG dose groups: Dose 0: 0 IU/day, Dose 50: 50 IU/day, Dose 100: 100 IU/day and Dose 150: 150 IU/day. RESULTS A significant hCG dose-dependent incremental increase was found for progesterone (49-160%), 17-OH-progesterone (223-614%), androstenedione (91-340%) and testosterone (95-338%) from Dose 0 to Dose 150, respectively. Dehydroepiandrosterone (DHEA) showed minor changes during stimulation and no differences between the groups. The highest oestradiol concentrations were observed in Dose 100 and Dose 150. Sex hormone-binding globulin (SHBG) increased similarly in all groups at the end of stimulation. No difference was observed for anti-müllerian hormone (AMH) concentration between the groups, but a 50% decline from the start to the end of the stimulation was found. CONCLUSION Supplementation with hCG resulted in a clear dose-related response for androgens, progesterone and 17-OH-progesterone. Oestradiol concentration reached maximum levels with an hCG dose of 100 IU/day, suggesting saturation of aromatase function. No difference between the groups was observed for DHEA, supporting that the stimulatory effects of hCG doses on androgens and oestrogen production were mainly induced via the Δ-5 pathway. SHBG, being a biomarker of oestrogen/androgen balance, was not changed by increasing hCG.
Collapse
Affiliation(s)
- L L Thuesen
- The Fertility Clinic, Section 4071, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | |
Collapse
|
35
|
|
36
|
Maldonado LGL, Franco JG, Setti AS, Iaconelli A, Borges E. Cost-effectiveness comparison between pituitary down-regulation with a gonadotropin-releasing hormone agonist short regimen on alternate days and an antagonist protocol for assisted fertilization treatments. Fertil Steril 2013; 99:1615-22. [DOI: 10.1016/j.fertnstert.2013.01.095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 01/07/2013] [Accepted: 01/09/2013] [Indexed: 11/30/2022]
|
37
|
Martins WP, Vieira ADD, Figueiredo JBP, Nastri CO. FSH replaced by low-dose hCG in the late follicular phase versus continued FSH for assisted reproductive techniques. Cochrane Database Syst Rev 2013:CD010042. [PMID: 23543584 DOI: 10.1002/14651858.cd010042.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND During controlled ovarian hyperstimulation (COH) follicle-stimulating hormone (FSH) is frequently used for several days to achieve follicular development. FSH is a relatively expensive drug, substantially contributing to the total expenses of assisted reproductive techniques (ART). When follicles achieve a diameter greater than 10 mm they start expressing luteinising hormone (LH) receptors. At this point, FSH might be replaced by low-dose human chorionic gonadotropin (hCG), which is less expensive. In addition to cost reduction, replacing FSH by low-dose hCG has a theoretical potential to reduce the incidence of ovarian hyperstimulation syndrome (OHSS). OBJECTIVES To evaluate the effectiveness and safety of using low-dose hCG to replace FSH during the late follicular phase in women undergoing COH for assisted reproduction, compared to the use of a conventional COH protocol. SEARCH METHODS We searched for randomised controlled trials (RCT) in electronic databases (Menstrual Disorders and Subfertility Group Specialized Register, CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS), trials registers (ClinicalTrials.gov, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform), conference abstracts (ISI Web of knowledge), and grey literature (OpenGrey); additionally we handsearched the reference list of included studies and similar reviews. The last electronic search was performed in February 2013.. SELECTION CRITERIA Only true RCTs comparing the replacement of FSH by low-dose hCG during late follicular phase of COH were considered eligible; quasi or pseudo-randomised trials were not included. Cross-over trials would be included only if data regarding the first treatment of each participant were available; trials that included the same participant more than once would be included only if each participant was always allocated to the same intervention and follow-up periods were the same in both/all arms, or if data regarding the first treatment of each participant were available. We excluded trials that sustained FSH after starting low-dose hCG and those that started FSH and low-dose hCG at the same time. DATA COLLECTION AND ANALYSIS Study eligibility, data extraction, and assessment of the risk of bias were performed independently by two review authors, and disagreements were solved by consulting a third review author. We corresponded with study investigators in order to solve any query, as required. The overall quality of the evidence was assessed in a GRADE summary of findings table. MAIN RESULTS The search retrieved 1585 records; from those five studies were eligible, including 351 women (intervention = 166; control = 185). All studies were judged to be at high risk of bias. All reported per-woman rather than per-cycle data.When use of low-dose hCG to replace FSH was compared with conventional COH for the outcome of live birth, confidence intervals were very wide and findings were compatible with appreciable benefit, no effect or appreciable harm for the intervention (RR 1.56, 95% CI 0.75 to 3.25, 2 studies, 130 women, I² = 0%, very-low-quality evidence). This suggests that for women with a 14% chance of achieving live birth using conventional COH, the chance of achieving live birth using low-dose hCG would be between 10% and 45%.Similarly confidence intervals were very wide for the outcome of OHSS and findings were compatible with benefit, no effect or harm for the intervention (OR 0.30, 95% CI 0.06 to 1.59, 5 studies, 351 women, I² = 59%, very-low-quality evidence). This suggests that for women with a 3% risk of OHSS using conventional COH, the risk using low-dose hCG would be between 0% and 4%.The confidence intervals were wide for the outcome of ongoing pregnancy and findings were compatible with benefit or no effect for the intervention (RR 1.14, 95% CI 0.81 to 1.60, 3 studies, 252 women, I² = 0%, low-quality evidence). This suggests that for women with a 32% chance of achieving ongoing pregnancy using conventional COH, the chance using low-dose hCG would be between 27% and 53%.The confidence intervals were wide for the outcome of clinical pregnancy and findings were compatible with benefit or no effect for the intervention (RR 1.19, 95% CI 0.92 to 1.55, 5 studies, 351 women, I² = 0%, low-quality evidence). This suggests that for women with a 35% chance of achieving clinical pregnancy using conventional COH, the chance using low-dose hCG would be between 32% and 54%.The confidence intervals were very wide for the outcome of miscarriage and findings were compatible with benefit, no effect or harm for the intervention (RR 1.08, 95% CI 0.50 to 2.31, 3 studies, 127 pregnant women, I² = 0%, very-low-quality evidence). This suggests that for pregnant women with a 16% risk of miscarriage using conventional COH, the risk using low-dose hCG would be between 8% and 36%.The findings for the outcome of FSH consumption were compatible with benefit for the intervention (MD -639 IU, 95% CI -893 to -385, 5 studies, 333 women, I² = 88%, moderate-quality evidence).The findings for the outcome of number of oocytes retrieved were compatible with no effect for the intervention (MD -0.12 oocytes, 95% CI -1.0 to 0.8 oocytes, 5 studies, 351 women, I² = 0%, moderate-quality evidence). AUTHORS' CONCLUSIONS We are very uncertain of the effect on live birth, OHSS and miscarriage of using low-dose hCG to replace FSH during the late follicular phase of COH in women undergoing ART, compared to the use of conventional COH. The current evidence suggests that this intervention does not reduce the chance of ongoing and clinical pregnancy; and that it is likely to result in an equivalent number of oocytes retrieved expending less FSH. More studies are needed to strengthen the evidence regarding the effect of this intervention on important reproductive outcomes.
Collapse
Affiliation(s)
- Wellington P Martins
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | | | | |
Collapse
|
38
|
Arce JC, Smitz J. Live-birth rates after HP-hMG stimulation in the long GnRH agonist protocol: association with mid-follicular hCG and progesterone concentrations, but not with LH concentrations. Gynecol Endocrinol 2013; 29:46-50. [PMID: 22809021 PMCID: PMC3518295 DOI: 10.3109/09513590.2012.705379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this retrospective study was to investigate the impact of endogenous and exogenous luteinizing hormone (LH) activity on treatment outcome, when taking into consideration potential confounding variables. Data were derived from IVF patients (n = 358) stimulated with highly purified menotrophin (HP-hMG) in a long gonadotrophin-releasing hormone (GnRH) agonist protocol. Simple retrospective logistic regression analysis showed that the mid-follicular exogenous concentrations of human chorionic gonadotrophin (hCG) (p = 0.027), provided by the HP-hMG preparation, and female age (p = 0.009) were significantly associated with live-birth rate, while the mid-follicular progesterone concentration (p = 0.075), the estradiol concentration on last stimulation day (p = 0.075) and number of embryos transferred (p = 0.071) were borderline significant. Endogenous LH was not associated with live-birth rate; neither at start of stimulation (p = 0.123), nor in the mid-follicular phase (p = 0.933) or on the last day of stimulation (p = 0.589). In the multiple regression analysis of life birth, mid-follicular hCG (p = 0.016) was identified as a positive predictor, and age (p = 0.004) and mid-follicular progesterone (p = 0.029) as negative predictors. In conclusion, mid-follicular concentrations of exogenous hCG and progesterone, but not endogenous LH, are associated with live-birth rate in IVF patients treated with HP-hMG in a long GnRH agonist cycle.
Collapse
Affiliation(s)
- Joan-Carles Arce
- Reproductive Health, Global Clinical & Non-Clinical R&D, Ferring Pharmaceuticals A/S, Copenhagen, Denmark.
| | | |
Collapse
|
39
|
Efficacy of low dose hCG on oocyte maturity for ovarian stimulation in poor responder women undergoing intracytoplasmic sperm injection cycle: a randomized controlled trial. J Assist Reprod Genet 2012; 29:1213-20. [PMID: 22956348 DOI: 10.1007/s10815-012-9854-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 08/21/2012] [Indexed: 01/27/2023] Open
Abstract
PURPOSE To investigate the effect of late follicular administration of low dose hCG on oocyte maturity in poor responding women undergoing intracytoplasmic sperm injection (ICSI). MATERIALS AND METHODS This prospective randomized pilot trial was performed on 73 poor responders undergoing ICSI, in Reproductive Biomedicine Research Center, Royan Institute, Tehran, Iran. All eligible patients underwent a GnRH-a long protocol and were randomly allocated into three study groups for ovarian stimulation: groupA received recombinant FSH alone, group B received recombinant FSH supplemented by 100 IU hCG. Group C received recombinant FSH supplemented by 200 IU hCG. The main endpoint was the number of metaphase II oocytes retrieved. RESULTS Of 78 poor responding patients entered to this study, 73 women were considered eligible for enrolment. Of these, 26 women were allocated to receive only recombinant FSH, 24 patients allocated to receive recombinant FSH and 100 IU hCG and 23 patients were assigned to receive recombinant FSH and 200 IU hCG. Number of oocytes retrieved were significantly higher in group B compared to group A (6.5 ± 3.3 versus 4.0 ± 2.3; P = .03). Other cycle and clinical outcomes were comparable between three groups. CONCLUSIONS The present study demonstrated that adding 100 IU hCG to rFSH in a GnRH agonist cycle in poor responders improve response to stimulation whereas the number of metaphase II oocytes remains comparable between groups. The existence of a possible trend toward higher mature oocytes and lower total dosage rFSH in patients received 100 or 200 IU hCG is probably due to the small sample size that means further large clinical trials in a more homogenous population is required (clinical trial registration number; NCT01509833).
Collapse
|
40
|
Gomaa H, Casper RF, Esfandiari N, Chang P, Bentov Y. Addition of low dose hCG to rFSh benefits older women during ovarian stimulation for IVF. Reprod Biol Endocrinol 2012; 10:55. [PMID: 22866896 PMCID: PMC3464931 DOI: 10.1186/1477-7827-10-55] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 07/25/2012] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND To compare the outcome of IVF cycles in women receiving controlled ovarian stimulation with recFSH or recFSH plus low dose hCG. METHODS A retrospective case control study, performed at a private practice affiliated with an academic institute. Patients were infertile women who were treated with IVF/ICSI and controlled ovarian stimulation in a long GnRH agonist protocol using either low dose hCG in addition to recFSH [N = 88] or recFSH alone [N = 99]. Primary outcomes were mean FSH dose, number of mature eggs, number of fertilized eggs, and serum levels of estradiol. Secondary outcomes were endometrial thickness, cycle cancellations and pregnancy rates. RESULTS A significant increase in number of mature and fertilized eggs was observed in women over 40 years of age using low dose hCG in addition to recFSH. The estradiol level was significantly higher on the day of hCG administration and the serum level of FSH on cycle day 7 and on the day of hCG administration were lower. CONCLUSION Addition of low dose hCG to recFSH compared with recFSH alone significantly modified cycle characteristics in patients >/= 40 years and could be of potential benefit for IVF cycles in older infertile women.
Collapse
Affiliation(s)
- Hala Gomaa
- Toronto Centre for Advanced Reproductive Technology, M5X 2 S9, Toronto, ON, Canada
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Robert F Casper
- Toronto Centre for Advanced Reproductive Technology, M5X 2 S9, Toronto, ON, Canada
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Navid Esfandiari
- Toronto Centre for Advanced Reproductive Technology, M5X 2 S9, Toronto, ON, Canada
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Paul Chang
- Toronto Centre for Advanced Reproductive Technology, M5X 2 S9, Toronto, ON, Canada
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Yaakov Bentov
- Toronto Centre for Advanced Reproductive Technology, M5X 2 S9, Toronto, ON, Canada
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| |
Collapse
|
41
|
Thuesen L, Loft A, Egeberg A, Smitz J, Petersen J, Nyboe Andersen A. A randomized controlled dose–response pilot study of addition of hCG to recombinant FSH during controlled ovarian stimulation for in vitro fertilization. Hum Reprod 2012; 27:3074-84. [DOI: 10.1093/humrep/des256] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
42
|
Checa MA, Espinós JJ, Requena A. Efficacy and safety of human chorionic gonadotropin for follicular phase stimulation in assisted reproduction: a systematic review and meta-analysis. Fertil Steril 2012; 97:1343-50.e1-3. [DOI: 10.1016/j.fertnstert.2012.02.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 02/01/2012] [Accepted: 02/29/2012] [Indexed: 11/13/2022]
|
43
|
Yu HT, Lee CL, Huang HY, Soong YK. Successful pregnancy in a woman with Kallmann's syndrome using human menopausal gonadotropin followed by low-dose human chorionic gonadotropin in the mid-to-late follicular phase. Taiwan J Obstet Gynecol 2012; 51:300-2. [DOI: 10.1016/j.tjog.2012.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2012] [Indexed: 11/17/2022] Open
|
44
|
Revelli A, Chiado' A, Guidetti D, Bongioanni F, Rovei V, Gennarelli G. Outcome of in vitro fertilization in patients with proven poor ovarian responsiveness after early vs. mid-follicular LH exposure: a prospective, randomized, controlled study. J Assist Reprod Genet 2012; 29:869-75. [PMID: 22644636 DOI: 10.1007/s10815-012-9804-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 05/20/2012] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To compare early vs. mid-follicular exposure to LH in patients with poor ovarian responsiveness undergoing in vitro fertilization (IVF). DESIGN Prospective, randomized, controlled trial. SETTING University Hospital, University-affiliated private Clinic. PATIENTS Five hundred-thirty women with poor ovarian responsiveness during the first IVF cycle, undergoing their second IVF attempt. INTERVENTIONS In a GnRH-analogue long protocol, ovarian stimulation with recombinant FSH (300 IU/day) plus randomly assigned addition of recombinant LH (150 IU/day) from day 1 (early LH exposure; n = 264) or from day 7 (late LH exposure; n = 266). MAIN OUTCOME MEASURE(S) Primary outcome was the number of oocytes retrieved. Secondary outcomes were: cancellation rate, total gonadotropin dose, duration of ovarian stimulation, number of embryos available for transfer, pregnancy rate per started cycle, per OPU and per embryo transfer, implantation rate, delivered/ongoing pregnancy rate. RESULTS Apart from the totally administered LH dose, that was significantly higher in the group receiving it from day 1, all parameters related to IVF outcome were non significantly different in the two groups. CONCLUSIONS Adding LH to FSH from day 1 or from day 7 of ovarian stimulation in a GnRH-agonist long protocol exerts comparable effects on IVF outcome in poor responders.
Collapse
Affiliation(s)
- Alberto Revelli
- Physiopathology of Reproduction and IVF Unit, S. Anna Hospital, University of Torino, Via Ventimiglia 3, Turin, Italy.
| | | | | | | | | | | |
Collapse
|
45
|
Efficacy of low-dose hCG in late follicular phase in controlled ovarian stimulation using GnRH agonist protocol. Arch Gynecol Obstet 2012; 286:771-5. [DOI: 10.1007/s00404-012-2337-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
|
46
|
Bosdou JK, Venetis CA, Kolibianakis EM, Toulis KA, Goulis DG, Zepiridis L, Tarlatzis BC. The use of androgens or androgen-modulating agents in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis. Hum Reprod Update 2012; 18:127-45. [PMID: 22307331 DOI: 10.1093/humupd/dmr051] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The aim of this meta-analysis was to evaluate the role of androgens or androgen-modulating agents on the probability of pregnancy achievement in poor responders undergoing IVF. METHODS Medline, EMBASE, CENTRAL, Scopus and Web of Science databases were searched for the identification of randomized controlled trials evaluating the administration of testosterone, dehydroepiandrosterone (DHEA), aromatase inhibitors, recombinant luteinizing hormone (rLH) and recombinant human chorionic gonadotrophin (rhCG) before or during ovarian stimulation of poor responders. RESULTS In two trials involving 163 patients, pretreatment with transdermal testosterone was associated with an increase in clinical pregnancy [risk difference (RD): +15%, 95% confidence interval (CI): +3 to +26%] and live birth rates (RD: +11%, 95% CI: +0.3 to +22%) in poor responders undergoing ovarian stimulation for IVF. No significant differences in clinical pregnancy and live birth rates were observed between patients who received DHEA and those who did not. Similarly, (i) the use of aromatase inhibitors, (ii) addition of rLH and (iii) addition of rhCG in poor responders stimulated with rFSH for IVF were not associated with increased clinical pregnancy rates. In the only eligible study that provided data, live birth rate was increased in patients who received rLH when compared with those who did not (RD: +19%, 95% CI:+1 to +36%). CONCLUSIONS Based on the limited available evidence, transdermal testosterone pretreatment seems to increase clinical pregnancy and live birth rates in poor responders undergoing ovarian stimulation for IVF. There is insufficient data to support a beneficial role of rLH, hCG, DHEA or letrozole administration in the probability of pregnancy in poor responders undergoing ovarian stimulation for IVF.
Collapse
Affiliation(s)
- J K Bosdou
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | | | | | | |
Collapse
|
47
|
Hill MJ, Levy G, Levens ED. Does exogenous LH in ovarian stimulation improve assisted reproduction success? An appraisal of the literature. Reprod Biomed Online 2011; 24:261-71. [PMID: 22285265 DOI: 10.1016/j.rbmo.2011.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 11/11/2011] [Accepted: 12/14/2011] [Indexed: 10/14/2022]
Abstract
A review of the scientific literature on the use of exogenous LH in assisted reproductive technology was performed by searching the MEDLINE, PubMed and Cochrane online databases. Scientific evidence was reviewed comparing recombinant FSH-only protocols to protocols supplemented with exogenous LH activity: human menopausal gonadotrophin (HMG), recombinant LH and mid-follicular human chorionic gonadotrophin (HCG). Studies were further compared based on pituitary suppression with gonadotrophin- releasing hormone (GnRH) antagonist and agonist protocols. Primary focus was given to randomized controlled trials and meta-analyses. Data from hypogonadotrophic hypogonadal patients demonstrated the importance of LH activity for success of assisted reproduction treatment. However, the majority of normogonadotrophic patients had adequate endogenous LH to successfully drive ovarian steroidogenesis and oocyte maturation. Exogenous LH supplementation was consistently associated with higher peak oestradiol concentrations. The use of HMG in long GnRH agonist cycles was associated with a 3–4% increase in live birth rate. There was insufficient evidence to make definitive conclusions on the need for exogenous LH activity in GnRH antagonist cycles or the benefit of recombinant LH and HCG protocols. Poor responders and patients 35 years of age and older may benefit from exogenous LH.
Collapse
Affiliation(s)
- Micah J Hill
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, MD 20892, USA
| | | | | |
Collapse
|
48
|
Hugues JN. Impact of 'LH activity' supplementation on serum progesterone levels during controlled ovarian stimulation: a systematic review. Hum Reprod 2011; 27:232-43. [PMID: 22081246 DOI: 10.1093/humrep/der380] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The influence of LH on serum progesterone rise during gonadotrophin stimulation is a matter of debate. The purpose of this analysis was to assess the impact of supplementation with 'LH activity' products on serum progesterone changes before hCG administration in GnRH analog-treated women. METHODS A computerized literature search was performed to identify studies comparing FSH treatment alone to those that provided supplementation with 'LH activity' using hMG, recombinant (r)LH (rLH) or hCG in GnRH analog protocols. Data regarding stimulation regimens were extracted from those that reported serum progesterone levels at the time of hCG in order to assess the specific role of LH activity products. RESULTS Serum progesterone determination at the time of hCG administration was performed in 34 out of 108 studies comparing the effects of FSH alone or in combination with LH activity products. In a vast majority, no significant difference in serum progesterone could be found between stimulation regimens. However, in four studies where LH activity (three hMG and one rLH) was administered from the beginning of ovarian stimulation, serum P-values were significantly decreased. In contrast, in two studies where LH activity (hCG) was provided during the late follicular phase, serum P-values were significantly increased. Analysis of confounding factors showed that the intensity of ovarian stimulation is the most important determining factor to explain serum progesterone elevation at the time of hCG administration, CONCLUSIONS This systematic review shows that providing LH activity supplementation in combination with FSH during ovarian stimulation does not have a consistent effect on serum progesterone concentrations at the time of hCG administration. However, these data also suggest that, in accordance with physiological concept, the timing of LH activity administration could influence the impact on serum progesterone changes.
Collapse
Affiliation(s)
- J N Hugues
- Reproductive Medicine Unit, Jean Verdier Hospital, University Paris XIII, Avenue du 14 Juillet, Bondy 93143, France.
| |
Collapse
|
49
|
Propst AM, Hill MJ, Bates GW, Palumbo M, Van Horne AK, Retzloff MG. Low-dose human chorionic gonadotropin may improve in vitro fertilization cycle outcomes in patients with low luteinizing hormone levels after gonadotropin-releasing hormone antagonist administration. Fertil Steril 2011; 96:898-904. [PMID: 21839437 DOI: 10.1016/j.fertnstert.2011.06.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/27/2011] [Accepted: 06/30/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effect of low levels of endogenous luteinizing hormone (LH) and low-dose human chorionic gonadotropin (hCG) supplementation on in vitro fertilization (IVF) cycle outcomes in a gonadotropin-releasing hormone (GnRH) antagonist protocol. DESIGN Retrospective study. SETTING Military medical center. PATIENT(S) General in vitro fertilization/embryo transfer (IVF-ET) population. INTERVENTION(S) Addition of low-dose urinary hCG to IVF stimulations using a recombinant follicle-stimulating hormone (FSH) and GnRH antagonist protocol. MAIN OUTCOME MEASURE(S) Implantation and live-birth rates. RESULT(S) As part of a larger cohort of 239 patients, 42 patients with LH levels ≤ 0.5 mIU/mL were evaluated. In the larger cohort, there were no differences in implantation and pregnancy rates between the recombinant FSH only (n = 113) and the recombinant FSH with low-dose hCG supplementation (n = 126) groups. In the FSH-only group, patients with LH levels ≤ 0.5 mIU/mL had decreased implantation rates (19% vs. 42%) and live-birth rates (25% vs. 54%) as compared with patients with LH levels >0.5 mIU/mL. Low LH patients in the recombinant FSH with low-dose urinary hCG group had statistically significantly higher implantation rates (54% vs. 19%) and live-birth rates (64% vs. 25%) as compared with patients with similar low LH levels in the recombinant FSH-only group. CONCLUSION(S) Endogenous LH levels ≤ 0.5 mIU/mL after GnRH antagonist treatment are associated with statistically significantly lower implantation and pregnancy rates in recombinant FSH-only cycles. The addition of low-dose urinary hCG results in improved implantation and live-birth rates in patients with low LH levels.
Collapse
Affiliation(s)
- Anthony M Propst
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Var T, Tonguc E, Dogan M, Mollamahmutoglu L. Relationship between the oestradiol/oocyte ratio and the outcome of assisted reproductive technology cycles with gonadotropin releasing hormone agonist. Gynecol Endocrinol 2011; 27:558-61. [PMID: 20642381 DOI: 10.3109/09513590.2010.501887] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to evaluate the relationship of oestradiol level on the day of hCG (peak E2)/oocyte ratio and the outcome of ART cycles. Of the patients who underwent IVF-ET, 600 normal and high responders to the first cycle of COH with gonadotropin releasing hormone (GnRH)-agonist were included in the study. Patients were designated into three groups based on peak E2/oocyte ratio (Group A: <100 pg/ml per oocyte, Group B: 100-200 pg/ml per oocyte, Group C: >200 pg/ml per oocyte). A comparison among groups was made regarding ovarian stimulation characteristics, fertilisation, implantation and pregnancy rates. After the division based on E2/oocyte ratio, in Group C, the number of oocytes retrieved, 2PN and M2 oocyte were statistically lower than both of the other two groups (p = 0.001, 0.001, 0.001, 0.045). HCG day E2 level was significantly different in all groups (p = 0.001), and fertilisation rate was meaningfully highest in Group C and lowest in Group A (p = 0.001). No difference existed among the three groups with respect to the number of embryos transferred and implantation rates. However, clinical pregnancy rate was significantly lower in Group A than others (p = 0.04). In ART cycles suppressed by GnRH-agonist, IVF outcomes are lower in patients with an E2/oocyte proportion of <100 pg/ml per oocyte.
Collapse
Affiliation(s)
- Turgut Var
- Zekai Tahir Burak Women's Health Research and Education Hospital, Department of Reproductive Endocrinology, Ankara, Turkey
| | | | | | | |
Collapse
|